Providers to FHCP Members From: FHCP Quality Management Date

To:
Providers to FHCP Members
From:
FHCP Quality Management
Date:
February 7, 2014
Subject:
HEDIS Respiratory Quality Measures 2014 Update, & Resource Tools
FHCP’s Quality Management Department shares your goal of delivering high quality care.
We follow current clinical practice guidelines for respiratory conditions and are monitored on an
ongoing basis by HEDIS (Healthcare Effectiveness Data and Information Set). HEDIS is a widely
used set of quality measures developed by the National Committee for Quality Assurance (NCQA)
to ensure high healthcare standards.
Enclosed is updated information for the HEDIS 2014 specifications relating to respiratory
conditions, i.e. Asthma, COPD (for Adult Members Only), Pharyngitis/Strep Tests, Upper
Respiratory Infections, Acute Bronchitis (for Adult Members Only), and use of Antibiotics.
Provided is a brief description of these quality measures for 2014, along with steps you and your
staff can take to ensure compliance with recommended clinical guidelines. Coding requirements
and medication lists are also included when applicable.
Please help us ensure optimal patient care by taking the time to read the summary of the
2014 specifications and using them in your treatment of FHCP patients.
Clinical Practice Guidelines and the attached Respiratory Conditions office resource tools and
CDC fact sheets are on our website at http://www.fhcp.com/providers/medical-guidelines/.
For questions concerning these quality measures, or to request copies of any materials, please call
Quality Management @ 676-7100, ext. 7258 or email [email protected].
Thank you for all you do on behalf of FHCP members and their continued health and wellness.
cc: Joseph Zuckerman, M.D., Chief Medical Officer
Changes to HEDIS ASM 2014 include: Coding tables were replaced with value set references,
and 3 medications (none on formulary) were removed from ASM-D, Asthma Controller Medications.
Use of Appropriate Medications for People With Asthma (ASM)
Description of the 2014 ASM measure: The measure looks at members 5-64 years of age who were
identified as having persistent asthma and who were prescribed appropriate controller medication
during the measurement year.
Patients with persistent asthma are identified as having met at least one (1) of the following criteria
during both the measurement year and the year prior:




At least one ED visit with asthma as the principal diagnosis.
At least one acute inpatient claim/encounter with asthma as the principal diagnosis.
At least four (4) outpatient asthma visits on different dates of service, with asthma as one of the
listed diagnoses and at least two asthma medication dispensing events.
At least four asthma medication dispensing events.
Generally, the majority of patients who fall onto the ASM Non-Compliant list have received 4 or more
fast acting rescue inhalers within each year, without the addition of an asthma controller medication.
Steps you can take:
1.
If your patient has persistent asthma and is not on a controller medication, please review and
consider initiation of this treatment as recommended in the Asthma Guidelines Summary for the
diagnosis and management of asthma. See attached ASM-D: Asthma Controller Medications
(new list for 2014).
2.
Be aware that the patient will state their symptoms are under control (per their perception) while
using frequent rescue inhalers. Additional refills are requested, and use of a suppressant/controller
medication is not addressed. Monitor the # of rescue inhalers the patient is refilling.
3.
Explain to the patient that using an asthma controller medication should lessen asthma
exacerbations and the need for rescue inhalers.
4.
If your patient has been dispensed a sample controller medication, please fax a copy to Quality
Management, Fax # (386) 481-5088, Attn: ASM Measure.
To view the Asthma Guidelines Summary, go to:
http://www.fhcp.com/providers/medical-guidelines/clinical-practice-guidelines
FHCP Quality Management, Spring 2014
2014 HEDIS Specifications
ASM-D: Asthma Controller Medications
RED indicates those available on FHCP formulary. Please refer to formulary for updates.
Description
Prescriptions
Antiasthmatic
combinations

dyphylline-guaifenesin
(COPD, Dilor-G, Lufyllin-Gc)

guaifenesin-theophylline
(Bronkaid, Quibron,
Quibron-300)
Antibody inhibitor

omalizumab (Xolair)
Inhaled steroid
combinations

budesonide-formoterol
(Symbicort)

fluticasone-salmeterol
(Advair)

mometasone-formoterol
(Dulera)
Inhaled corticosteroids

beclomethasone (Qvar)

flunisolide (Aerobid)

mometasone (Asmanex)

budesonide (Pulmicort Respules)
(Peds only)

fluticasone CFC free
(Flovent)

triamcinolone (Azmacort)

ciclesonide (Alvesco)
Leukotriene modifiers

montelukast (Singulair)

zafirlukast (Accolate)

zileuton (Zyflo)
Mast cell stabilizers

cromolyn (Intal)
Methylxanthines

aminophylline (Phyllocontin,
Truphylline)

theophylline
(Theo-Dur, Respbid, Slo-Bid, Theo-24, Theolair)

dyphylline (Dilor, Dylix, Lufyllin)
Medication Management for People With Asthma (MMA)
Description of the 2014 ASM measure: The percentage of members 5–64 years of age during the
measurement year who were identified as having persistent asthma and were dispensed appropriate
medications that they remained on during the treatment period. Two rates are reported:
1. The percentage of members who remained on an asthma controller medication (ASM-D) for at
least 50% of their treatment period.
2. The percentage of members who remained on an asthma controller medication (ASM-D) for at
least 75% of their treatment period.
Asthma Medication Ratio (AMR)
Description of the 2014 ASM measure: The percentage of members 5–64 years of age who were
identified as having persistent asthma and had a ratio of controller medications to total asthma
medications of 0.50 or greater during the measurement year.
Step 1: For each member, count the units of controller medications (AMR-A) dispensed during the
measurement year. Each dispensing event is one unit. When inhalers are used, one medication unit
equals one inhaler (canister) dispensed.
Step 2: For each member, count the units of reliever medications (AMR-A) dispensed during the
measurement year. Each dispensing event is one unit. When inhalers are used, one medication unit
equals one inhaler (canister) dispensed.
Step 3: For each member, sum the units calculated in step 1 and step 2 to determine units of total asthma
medications.
Step 4: For each member, calculate the ratio of controller medications to total asthma medications using
the following formula.
Units of Controller Medications (step 1)
Units of Total Asthma Medications (step 3)
Step 5: Sum the total number of members who have a ratio of 0.50 or greater in step 4.
Note: Multiple inhaler dispensing events of the same inhaler medication or a different inhaler
medication count as separate dispensing events. For example, two inhalers dispensed on the same or
different days count as two dispensing events.
FHCP Quality Management, Spring 2014
2014 HEDIS Specifications
AMR-A: Asthma Controller and Reliever Medications
Description
Asthma Controller Medications
Prescriptions
Antiasthmatic
combinations
 dyphylline-
Antibody inhibitors
 omalizumab
Inhaled steroid
combinations
 budesonide-
 fluticasone-
 mometasone-
Inhaled
corticosteroids
 beclomethasone
 budesonide
 ciclesonide
 flunisolide
 fluticasone CFC
 triamcinolone
Leukotriene
modifiers
Mast cell stabilizers
 montelukast
 zafirlukast
Methylxanthines
 aminophylline
 dyphylline
Description
Short-acting, inhaled
beta-2 agonists
guaifenesin
formoterol
 guaifenesin-
theophylline
salmeterol
formoterol
free
 mometasone
 zileuton
 cromolyn
 theophylline
Asthma Reliever Medications
Prescriptions
 albuterol
 metaproterenol
 levalbuterol
 pirbuterol
Note
The HEDIS age strata for asthma measures are designed to align with both clinical practice
guidelines and reporting requirements for child health quality improvement programs. Clinical
guidelines specify appropriate age cohorts for measuring use of asthma medications as 5–11
years and 12–50 years, to account for differences in medication regimens for children vs.
regimens for adolescents and adults. Implementation requires further stratification of age
ranges to enable creation of comparable cohorts that align with child health populations.
Changes to HEDIS PCE 2014 include: Coding tables were replaced with value set references, and 1 Bronchodilator
(aclidinium-bromide/Tudorza) was added to PCE-D.
Pharmacotherapy Management of COPD Exacerbation (PCE)
Description of the 2014 PCE measure: The percentage of COPD exacerbations for members
40 years of age and older who had an acute inpatient discharge or ED visit between Jan 1 – Nov
30, and who were dispensed appropriate medications.
To comply with the PCE standard and ensure the most optimal return to health, these members
are given both of the following medications within a specified time frame:
 Dispensed a systemic corticosteroid within 14 days of the Episode Date.
 Dispensed a bronchodilator within 30 days of the Episode Date.
The Episode Date for Inpatient Hospitalization is the date of discharge, while the Emergency
Room visit Episode Date is the date the patient was seen in the ER. Most patients receive
prescriptions upon release from the hospital, but this is not always the case.
Steps you can take:
1. When your patient has been discharged from an inpatient stay or ED visit for COPD,
please contact them to schedule a follow-up appointment as soon as possible, but no later
than within 14 days, for re-evaluation and medication management.
2. Ask patients if they filled a corticosteroid, or a bronchodilator prescription.
Patients must actually fill the prescription for compliance with the measure.
3. If the hospital staff did not prescribe a corticosteroid or a bronchodilator, it would be
helpful if FHCP providers could write the prescriptions, and encourage their patients
to fill the prescription within the allotted time of 14 or 30 days respectively.
You may go to http://www.fhcp.com/providers/medical-guidelines/clinical-practiceguidelines to view the COPD Guidelines.
Attached for your review are the medications listed in the HEDIS specifications for PCE:
 PCE-C: Systemic Corticosteroids
 PCE-D: Bronchodilators
FHCP Quality Management, Spring 2014
2014 HEDIS SPECIFICATIONS
PCE-C: Systemic Corticosteroids
RED indicates those available on FHCP formulary. Please refer to formulary for updates.
Description
Prescription
Glucocorticoids

betamethasone

hydrocortisone

prednisolone

dexamethasone

methylprednisolone

prednisone

triamcinolone
PCE-D: Bronchodilators
RED indicates those available on FHCP formulary. Please refer to formulary for updates.
Description

Anticholinergic
agents




Beta 2-agonists
Methylxanthines


albuterol-ipratropium
(Combivent)

ipratropium (Atrovent,
Combivent, DuoNeb)

aclidinium-bromide
(Tudorza)
albuterol (Accuneb,
ProAir HFA,
Proventil, Proventil
HFA, Ventolin
HFA,Volmax, Vospire)

arformoterol (Brovana)

budesonide-formoterol
(Symbicort)


fluticasone-salmeterol
(Advair Diskus)

aminophylline

dyphylline-guaifenesin

guaifenesintheophylline
tiotropium (Spiriva)



formoterol


metaproterenol (Alupent, Metaprel)

Indacaterol (Onbrez)

pirbuterol (Maxair Autohaler)

Levalbuterol (Xopenex)

salmeterol (Serevent Diskus)

mometasone-formoterol
(Dulera)




dyphylline

theophylline (Theo-Dur, Respid, Slo-Bid, Theo-24, Theolair, Uniphyl, Slo-Phyllin)
Changes to HEDIS CWP 2014 include: Coding tables were replaced with value set references.
Appropriate Testing for Children With Pharyngitis (CWP)
Description of the 2014 CWP measure: The percentage of children 2 – 18 years of age who were
diagnosed with Pharyngitis, dispensed an antibiotic and received a Group A streptococcus (strep) test for
the episode. A higher rate represents better performance (i.e. appropriate strep testing).
To clarify, a strep test should be completed and documented for any patient receiving a diagnosis
of Pharyngitis who is prescribed an antibiotic.
What we have found for members on the CWP Non-Compliant list:
 A strep test was not performed for a diagnosis of Pharyngitis, or
 The code for the strep test was not included on the claim, or
 Additional diagnoses other than Pharyngitis which are present on office visit notes, have not
been included on the actual claim. (This is important because more than 1 diagnosis on the
claim, other than Pharyngitis, removes a member from the CWP Non-Compliant list).
Pharyngitis Includes: ICD-9 Code
Acute Pharyngitis
462
Acute Tonsillitis
463
Streptococcal Sore
Throat
Codes to Identify Group A Strep Tests
87070, 87071, 87081, 87430, 87650, 87651, 87652, 87880
034.0
Steps you can take:
If a member age 2 to 18 has Pharyngitis (which includes Acute Pharyngitis, Acute Tonsillitis, or
Streptococcal Sore Throat), and you are prescribing an antibiotic:
1. Please complete a Strep Test.
2. Please include the CPT code for the Group A Strep Test.
3. Please include all diagnosis codes with the claim, if there are any other than Pharyngitis.
You may go to http://www.cdc.gov/getsmart/campaign-materials/treatment-guidelines.html to view
Pediatric & Adult Treatment Guidelines for various Upper Respiratory Infections.
FHCP Quality Management, Spring 2014
Changes to HEDIS URI 2014 include: Coding tables were replaced with value set references.
Appropriate Treatment for Children With Upper Respiratory Infection (URI)
Description of the 2014 URI measure: The percentage of children 3 months - 18 years of age who
were given a diagnosis of Upper Respiratory Infection (URI) and were not dispensed an antibiotic.
For Upper Respiratory Infections, it is considered a mark of high quality care if these patients were not
dispensed an antibiotic when they only have a diagnosis of a URI, which includes either:
 Acute Nasopharyngitis –“common cold” (Code 460); or
 Upper Respiratory Infection (Code 465).
As you are aware, Acute Nasopharyngitis (common cold), & Upper Respiratory Infections are usually
viral illnesses that do not respond to antibiotics. We understand that many parents do not believe that
antibiotics are not always appropriate when their child is sick. It takes everyone in healthcare working
together to diminish the use of antibiotics, and to avoid creating resistant strains of bacteria which are
dangerous to all of us.
Steps you can take:
1. When an antibiotic is being prescribed for one of our members age 3 months to 18 years, with
either Acute Nasopharyngitis (common cold – Code 460), or Upper Respiratory Infection (Code
465), please evaluate the use of an additional diagnosis, if appropriate, such as:
Otitis Media; Acute Sinusitis; Acute Pharyngitis; Acute Tonsillitis; Chronic Sinusitis; Infections of
the Pharynx, Larynx, Tonsils, Adenoids; Bacterial infection unspecified; Pertussis; or Pneumonia.
For a complete list, please see attached URI-C: Codes to Identify Competing Diagnoses.
2. If you are unable to add an additional diagnosis from URI-C, please consider not prescribing
an antibiotic if using only the diagnoses of Acute Nasopharyngitis (Code 460) and/or Upper
Respiratory Infection (Code 465).
Per national standards of care as contained in HEDIS specifications, antibiotic use is not
recommended for Acute Nasopharyngitis and/or Upper Respiratory Infection.
You may go to http://www.cdc.gov/getsmart/campaign-materials/onepage-sheets.html to print
education sheets (English/Spanish) to reinforce the decision to parents not to use an antibiotic.
FHCP Quality Management, Spring 2014
URI-C: Codes to Identify Competing Diagnoses
Description
Intestinal infections
ICD-9-CM Diagnosis
001-009
Pertussis
033
Bacterial infection unspecified
041.9
Lyme disease and other arthropod-borne diseases 088
Otitis media
382
Acute sinusitis
461
Acute pharyngitis
034.0, 462
Acute tonsillitis
463
Chronic sinusitis
473
Infections of the pharynx, larynx, tonsils,
adenoids
Prostatitis
464.1-464.3, 474, 478.21-478.24, 478.29, 478.71,
478.79, 478.9
601
Cellulitis, mastoiditis, other bone infections
383, 681, 682, 730
Acute lymphadenitis
683
Impetigo
684
Skin staph infections
686
Pneumonia
481- 486
Gonococcal infections and venereal diseases
098, 099, V01.6, V02.7, V02.8
Syphilis
090-097
Chlamydia
078.88, 079.88, 079.98
Inflammatory diseases (female reproductive
organs)
131, 614-616
Infections of the kidney
590
Cystitis or UTI
595, 599.0
Acne
706.0, 706.1
Changes to HEDIS AAB 2014 include: Coding tables were replaced with value set references.
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
Description of the 2014 AAB measure: The percentage of adults 18–64 years of age with a
diagnosis of Acute Bronchitis (ICD Code 466), who were not dispensed an antibiotic.
As you are aware, Acute Bronchitis is usually a viral illness that does not respond to antibiotics,
and therefore antibiotic treatment is not recommended for this diagnosis. Overuse of antibiotics
continues to be an ongoing problem in healthcare.
Attached for your review from the HEDIS specifications for AAB:
 URI-C:
Codes to Identify Competing Diagnoses
 AAB-C: Codes to Identify Comorbid Conditions
Steps you can take:
1. When an antibiotic is being prescribed for a patient with Code 466 - Acute Bronchitis,
please evaluate the use of an additional diagnosis (URI-C), or evaluate the use of a
comorbid condition (AAB-C), if appropriate to the patient.
2. If you are unable to add an appropriate additional diagnosis from URI-C, or an
appropriate comorbid condition from AAB-C, please consider not prescribing an
antibiotic for Acute Bronchitis. This is taken from the HEDIS specifications for
national standards of care for these patients.
Many times a patient believes an antibiotic is necessary to alleviate symptoms and may be
persistent in this request.
This is an opportunity to provide education on why antibiotics are not always necessary and can
even be harmful. Symptom management can be stressed.
You may go to http://www.cdc.gov/getsmart/ to view information from the CDC on
appropriate antibiotic use.
FHCP Quality Management, Spring 2014
URI-C: Codes to Identify Competing Diagnoses
Description
Intestinal infections
Pertussis
Bacterial infection unspecified
Lyme disease and other arthropod-borne
diseases
Otitis media
Acute sinusitis
Acute pharyngitis
Acute tonsillitis
Chronic sinusitis
Infections of the pharynx, larynx, tonsils,
adenoids
Prostatitis
Cellulitis, mastoiditis, other bone infections
Acute lymphadenitis
Impetigo
Skin staph infections
Pneumonia
Gonococcal infections and venereal diseases
Syphilis
Chlamydia
Inflammatory diseases (female reproductive
organs)
Infections of the kidney
Cystitis or UTI
Acne
ICD-9-CM Diagnosis
001-009
033
041.9
088
382
461
034.0, 462
463
473
464.1-464.3, 474, 478.21-478.24, 478.29, 478.71, 478.79,
478.9
601
383, 681, 682, 730
683
684
686
481- 486
098, 099, V01.6, V02.7, V02.8
090-097
078.88, 079.88, 079.98
131, 614-616
590
595, 599.0
706.0, 706.1
AAB-C: Codes to Identify Comorbid Conditions
Description
HIV disease; asymptomatic HIV
Cystic fibrosis
Disorders of the immune system
Malignancy neoplasms
Chronic bronchitis
Emphysema
Bronchiectasis
Extrinsic allergic alveolitis
Chronic airway obstruction, chronic obstructive asthma
Pneumoconiosis and other lung disease due to external
agents
Other diseases of the respiratory system
Tuberculosis
ICD-9-CM Diagnosis
042, V08
277.0
279
140-209
491
492
494
495
493.2, 496
500-508
510-519
010-018
Acute Bacterial Rhinosinusitis
Principles of appropriate antibiotic use for acute rhinosinusitis apply to the diagnosis and treatment
of acute maxillary and ethmoid rhinosinusitis in otherwise healthy adults.
Sinus inflammation is often viral and usually resolves without antibiotics.
■ Patients may rarely present with severe
Background
■ Respiratory viruses typically cause
inflammation of the nasal mucosa and
maxillary sinuses.
■ Most cases of acute rhinosinusitis are
due to uncomplicated viral infections.
Diagnosis
■ Most rhinovirus colds last 7 to 11 days
(J Clin Microbiol 1997; 35:2864; JAMA 1967;
202:158).
■ Bacterial rhinosinusitis may be present
if symptoms have been present >7 days
and there is localization to the maxillary
sinus.
Signs/Symptoms of
Acute Maxillary Sinusitis
(BMJ 1995;311:233)
Odds
Ratio
Fever
89%
79%
2.1
Unilateral
maxillary
pain
51%
38%
1.9
Maxillary
toothache
66%
51%
1.9
Unilateral
maxillary
sinus
tenderness
49%
for routine evaluation of acute,
uncomplicated bacterial rhinosinusitis.
Tell patients that antibiotic use increases the
risk of an antibioticresistant infection.
■
– Opacification and air-fluid level have
sensitivity of ~ 73% and specificity
of 80% (J Clin Epidemiol 2000;53:852).
Identify and validate
patient concerns.
■
Recommend specific
symptomatic therapy.
■
Spend time answering
questions and offer a
contingency plan if
symptoms worsen.
■
Provide patient education materials on
antibiotic resistance.
■
REMEMBER: Effective
communication is more
important than an
antibiotic for patient
satisfaction.
■
See www.cdc.gov/
drugresistance/community
or contact your local
health department for
more information and
patient education materials.
■ Sinus radiography is not recommended
– Mucosal abnormalities are common in
patients with viral infections (J Allergy
Clin Immunol 1998;102:403).
Treatment
■ Most patients with acute bacterial
rhinosinusitis improve without antibiotic
treatment.
■ Patients with mild symptoms should not
receive antibiotics, but symptomatic
treatment may be helpful.
– Topical and oral decongestants may
reduce nasal symptoms.
– Most randomized trials of symptomatic
therapies have been inconclusive.
■ Patients with moderate or severe symp-
toms may benefit from antibiotics.
32%
2.5
■ Generalized facial pain or tenderness,
postnasal drainage, headache, and cough
do not increase the predictive value of
maxillary sinus symptoms.
TIPS TO REDUCE
ANTIBIOTIC USE
■
– About 81% of antibiotic-treated patients
and 66% of controls are improved at
10-14 days (absolute benefit of 15%).
Maxillary
Sinusitis
Present Absent
(N=92) (N=82)
symptoms of bacterial rhinosinusitis less
than 7 days duration (acute focal
sinusitis). Consider immediate referral to
an otolaryngologist for evaluation and
drainage.
■ Use a narrow spectrum agent that
covers S. pneumoniae and H. influenzae.
– Amoxicillin remains an appropriate
choice for uncomplicated infections.
– Consider second line agent if no
improvement or worsening after
72 hours.
Key Reference
Hickner JM et al. Principles of
appropriate antibiotic use for acute
rhinosinusitis in adults: Background.
Annals of Internal Medicine 2001;
134(6):498-505.
Acute Cough Illness (Acute Bronchitis)
Acute bronchitis is an acute respiratory infection with a normal chest radiograph that is manifested by cough
with or without phlegm production that lasts for up to 3 weeks (Chest 2006;129:95S-103S).
Principles apply to the appropriate treatment of cough illness lasting less than 3 weeks in otherwise
healthy adults.
Refer to acute cough illness as a “chest cold”
to reduce patient expectation for antibiotics (Am J Med 2000;108-83).
Pi i l
l
Background
h
i
■ Greater than 90% of cases of acute cough
illness are non-bacterial.
- Viral etiologies include influenza,
parainfluenza, RSV, and adenovirus.
- Bacterial agents include Bordatella
pertussis, Mycoplasma pneumoniae,
and Chlamydophila pneumoniae.
■ The presence of purulent sputum is not
predictive of bacterial infection.
- >95% of patients with purulent sputum do
not have pneumonia (J Chron Di 1984;
37:215).
Diagnosis
■ Evaluation should focus on excluding
severe illness, particularly pneumonia.
Clinical Assessment for
Pneumonia
■ Pneumonia is unlikely if all of the
following findings are absent (JAMA
1997;278:1440).
Sign
Abnormal
Finding
Fever
≥ 38 C
Tachypnea
≥ 24 breaths/min
Tachycardia
≥ 100 beats/min
Evidence of
consolidation
on chest exam
rales, egophony,
fremitus
■ Consider chest radiograph for patients
with any of these findings or cough
lasting >3 weeks.
f
h ill
Treatment
l
i
l
h
■ Empiric antibiotic treatment is not
indicated for acute bronchitis.
- Meta-analyses of randomized,
controlled trials all concluded that
routine antibiotic treatment is not
justified (BMJ 1998;316:906; Chest
2006;129:95S-103S).
■ If influenza therapy is considered, it
should be initiated within 48 hours of
symptom onset for clinical benefit.
- During the 2005-06 Flu season CDC
recommends that neither amantadine nor
rimantadine be used for treatment or
prevention of influenza A infections
because of high levels of resistance
(MMWR 2006 Jan 20;55(2):44-6).
- Neuramidase inhibitors such as oseltamivir
or zanamivir have activity against influenza
A and B viruses.
- Antiviral therapy reduces symptom duration
by approximately 1 day.
http://www.cdc.gov/flu/professionals/treatment/
■ If pertussis is suspected, empiric therapy
may be initiated while obtaining a
diagnostic test for confirmation.
- Antibiotic treatment decreases transmission
but has little effect on symptom resolution.
■ Over-the-counter cough suppressants
have limited efficacy in relief of cough
due to acute bronchitis (Chest 2006;
3
k i
h
i
h lh
TIPS TO REDUCE
ANTIBIOTIC USE
■ Tell patients that antibiotic use increases the
risk of an antibioticresistant infection.
■ Identify and validate
patient concerns.
■ Recommend specific
symptomatic therapy.
■ Spend time answering
questions and offer a
contingency plan if
symptoms worsen.
■ Provide patient education
materials on antibiotic
resistance.
■ REMEMBER: Effective
communication is more
important than an
antibiotic for patient
satisfaction.
■ See www.cdc.gov/
getsmart or contact your
local health department
for more information and
patient education
materials.
129:95S-103S).
Key Reference
Gozales R et al. Principles of
appropriate antibiotic use for
treatment of uncomplicated acute
bronchitis: Background. Annals of
Internal Medicine 2001;
134(6):521-90.
Acute Pharyngitis in Adults
Principles apply to the diagnosis and treatment of Group A ß-hemolytic streptococcal (GABHS)
pharyngitis in otherwise healthy adults.
Clinical screening for GABHS pharyngitis could
substantially reduce unnecessary antibiotic use.
Background
■
Only 5-15% of adult cases of acute
pharyngitis are caused by GABHS.
It is estimated that 3,000 to 4,000
patients with GABHS must be
treated for every 1 case of acute
rheumatic fever prevented.
■ Antibiotic therapy of GABHS hastens
resolution by 1-2 days if initiated
within 2-3 days of symptom onset.
■
Diagnosis
■
Cultures are not recommended for routine
evaluation of adult pharyngitis or for
confirmation of negative results on rapid
antigen tests if test sensitivity >80%.
■ Throat cultures maybe useful for
outbreak investigation, monitoring
rates of antibiotic resistance, or when
other pathogens (e.g., gonococcus) are
being considered.
■
Comparison of
Diagnostic Strategies*
Lab testing is not indicated in all patients
with pharyngitis. Instead, all adults
should be screened for the following:
–
–
–
–
History of fever
Lack of cough
Tonsillar exudates
Tender anterior cervical adenopathy
Patients with none or only one of
these findings should not be tested
or treated for GABHS.
■ Rapid streptococcal antigen test (RAT)
is recommended for patients with
two or more criteria, with antibiotic
therapy restricted to those with positive
test results.
for patients with 2 or more criteria,
with antibiotic therapy restricted to
those with positive test results.
■
– Rapid streptococcal antigen testing
of patients with 2 or 3 criteria,
with antibiotic therapy restricted to
patients with all 4 findings and those
with positive test results.
– Empiric antibiotic therapy for
patients with 3 or 4 criteria; no
diagnostic testing.
Test for 2+
criteria and
treat positives
Empiric
treatment for
3-4 criteria
60%-70%
70%-80%
% of patients
with GABHS
who are
correctly
treated
% of patients
receiving
antibiotics
11%
TIPS TO REDUCE
ANTIBIOTIC USE
■
Tell patients that antibiotic use increases the
risk of an antibioticresistant infection.
■
Identify and validate
patient concerns.
■
Recommend specific
symptomatic therapy.
■
Spend time answering
questions and offer a
contingency plan if
symptoms worsen.
■
Provide patient education materials on
antibiotic resistance.
■
REMEMBER: Effective
communication is more
important than an
antibiotic for patient
satisfaction.
■
See www.cdc.gov/
getsmart or contact your
local health department
for more information and
patient education materials.
33%
*Assumptions: RAT sensitivity = 80%; RAT
specificity = 90%; GABHS prevalence = 10%.
Treatment
Penicillin is recommended for initial
treatment of GABHS.
– Erythromycin is recommended for
penicillin-allergic patients.
– Penicillin-resistant GABHS have
not been reported in the United
States.
■ Extended spectrum macrolides
and fluoroquinolones are not
appropriate for uncomplicated
GABHS pharyngitis.
■
Key Reference
Cooper RJ et al. Principles of
appropriate antibiotic use for acute
pharyngitis in adults: Background.
Annals of Internal Medicine
2001;134(6):509-17.
Adult Appropriate Antibiotic Use Summary
Diagnosis
CDC Principles of Appropriate Antibiotic Use
1. The diagnosis of nonspecific upper respiratory tract infections or acute rhinopharyngitis should be used to denote acute
Upper
infection that is typically viral in origin, and in which sinus, pharyngeal, and lower airway symptoms, although frequently
respiratory
present, are not prominent.
infections,
2.
Antibiotic treatment of nonspecific upper respiratory infections in adults does not enhance illness resolution or prevent
not
complications, and is therefore not recommended.
otherwise
3. Purulent secretions in the nares and throat (commonly reported and seen in patients with an uncomplicated, upper respiratory
specified
tract infection) neither predict bacterial infection nor benefit from antibiotic treatment.
1. Group A beta hemolytic streptococcus (GABHS) is the etiologic agent in approximately 10% of adult cases of pharyngitis.
Acute
The large majority of adults with acute pharyngitis have a self-limiting illness, which would do well with supportive care only.
pharyngitis
2. The benefits of antibiotic treatment of adult pharyngitis are limited to those patients with GABHS infection. All patients
with pharyngitis should be offered appropriate doses of analgesics, antipyretics and other supportive care.
3. Limit antibiotic prescriptions to those patients with the highest likelihood of GABHS.
A. Clinically screen all adult patients with pharyngitis for the presence of the 4 Centor criteria: (1) history of fever, (2)
tonsillar exudates, (3) no cough, and (4) tender anterior cervical lymphadenopathy (lymphadenitis).
B. Do not test and do not treat patients with none or only one of these criteria. These patients are unlikely to have
GABHS infection.
C. Test patients with 2 or more criteria using a rapid antigen test. Limit antibiotic therapy to patients with a positive test.
i. Test are
patients
with 2, 3, or 4for
criteria
using aprimary
rapid antigen
test.ofLimit
antibiotic
therapy tonor
patients
a positive
4. Throat cultures
not recommended
the routine
evaluation
adults
with pharyngitis,
for thewith
confirmation
of negative test.
rapid antigen tests. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for
monitoring
the development
of antibiotic
resistance,
when
pathogens
such
as gonococcus
being
considered.
ii. Test
patients with and
2 orspread
3 criteria
using a rapid
antigenortest.
Limit
antibiotic
therapy
to patientsare
with
a positive
test
or
patients
with
4
criteria.
5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin for a penicillin-allergic
patient.iii. Do not use any diagnostic tests. Limit antibiotic therapy to patients with 3 or 4 criteria.
4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis, nor for the confirmation
of negative rapid antigen tests. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for
monitoring the development and spread of antibiotic resistance, or when pathogens such as gonococcus are being considered.
5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin for a penicillin-allergic
patient.
Rhinosinusitis
1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are due to uncomplicated viral, upper respiratory tract
infections.
2. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial
rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more and who have maxillary
facial/tooth pain or tenderness (especially when unilateral) and purulent nasal secretions. Patients who have rhinosinusitis
symptoms for less than 7 days are unlikely to have a bacterial infection.
3. Sinus radiographs are not recommended for diagnosis in routine cases.
4. Acute bacterial rhinosinusitis resolves without antibiotic treatment in the majority of cases. Symptomatic treatment and
reassurance is the preferred, initial management strategy for patients with mild symptoms. Antibiotic therapy should be
reserved for patients meeting the criteria for the clinical diagnosis of acute bacterial rhinosinusitis who have moderately severe
symptoms, and for those with severe rhinosinusitis symptoms—especially those with unilateral face pain—regardless of
duration of illness. Initial treatment should be with the most narrow-spectrum agent that is active against likely pathogens
Streptococcus pneumoniae and Haemophilus influenzae.
Bronchitis
1. The evaluation of adults with an acute cough illness, or with presumptive diagnosis of uncomplicated acute bronchitis, should
focus on ruling out pneumonia. In the healthy, non-elderly adult, pneumonia is uncommon in the absence of vital sign
abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3
weeks or longer, chest radiography is warranted in the absence of other known causes.
2. Routine antibiotic treatment of uncomplicated bronchitis is not recommended, regardless of duration of cough. In the unusual
circumstance when pertussis infection is suspected, a diagnostic test should be performed and antimicrobial therapy initiated.
3. Patient satisfaction with care for acute bronchitis is most dependent on the doctor-patient
communication rather than on whether or not an antibiotic is prescribed.
Nonspecific Upper Respiratory Tract
Infection
Principles of appropriate antibiotic use apply to the diagnosis and treatment of acute upper
respiratory tract infection (common cold) in otherwise healthy adults.
Symptoms may last up to 10-14 days
Principles apply to the appropriate treatment of cough illness lasting less than 3 weeks in otherwise healthy
Background
Treatment
■ The common cold is caused by viral
pathogens, such as rhinovirus,
parainfluenza, adenovirus, RSV, and
influenza.
■ Studies have found the common
cold resolves without antibiotic
treatment.
■ Bacterial rhinosinusitis complicates only
about 2% of cases.
Diagnosis
■ Although sore throat, nasal symptoms,
and cough may be present, there is no
prominent symptom or sign.
■ Symptoms may last up to 14 days with an
average of 7 to 11 days (J Clin Microbiol
1997;35:2864; JAMA 1967;202:158).
■ Purulent nasal secretions do not predict
bacterial sinusitis unless accompanied by
other signs and symptoms of bacterial
infection.
■ Treatment with an antibiotic does
not shorten the duration of illness
or prevent bacterial rhinosinusitis.
■ Patients with purulent green or
yellow secretions do not benefit
from antibiotic treatment.
■ Over-the-counter cough
suppressants have limited efficacy
for relief of cough due to upper
respiratory infection (Chest 2006;
129:95S-103S).
■ Acute cough associated with the
common cold may be relieved by
first-generation antihistamines and
decongestants (Chest 2006;129:95S103S).
TIPS TO REDUCE
ANTIBIOTIC USE
■ Tell patients that antibiotic use increases the
risk of an antibioticresistant infection.
■ Identify and validate
patient concerns.
■ Recommend specific
symptomatic therapy.
■ Spend time answering
questions and offer a
contingency plan if
symptoms worsen.
■ Provide patient education
materials on antibiotic
resistance.
■ REMEMBER: Effective
communication is more
important than an
antibiotic for patient
satisfaction.
■ See www.cdc.gov/
getsmart or contact your
local health department
for more information and
patient education
materials.
Key Reference
Gozales R et al. Principles of
appropriate antibiotic use for
treatment of nonspecific upper
respiratory tract infection:
Background. Annals of Internal
Medicine 2001;134(6):490-4.
Gwaltney,JAMA 1967;202:158
CAREFUL ANTIBIOTIC USE
To avoid antibiotic resistance: treat only proven
group A strep
PHARYNGITIS IN CHILDREN1
“If you are entirely comfortable selecting
which pharyngitis patients to treat 10 days
with penicillin, perhaps you don’t understand the situation.”
- Stillerman and Bernstein, 1961
■ Most sore throats are caused by
viral agents.2
Experts discourage treatment pending
culture results5-6, but if you do...
■ Make sure to stop antibiotics when
culture is negative.
■ Discourage parents from saving
antibiotics.
If an antibiotic is prescribed:
■ Use a penicillin as treatment for
group A strep.7
NO group A strep are resistant to penicillin.
Treatment is 90% effective at elimination of
strep, and may be higher in the prevention of
acute rheumatic fever (ARF). Carriers are at
very low risk for both ARF and spreading
infection. 7
■ Use erythromycin if penicillin
■ Clinical findings alone do not
adequately distinguish Strep vs.
Non-Strep pharyngitis. 3
BUT, prominent rhinorrhea, cough, hoarseness,
conjuntivitis, or diarrhea suggest a VIRAL
etiology. 4
■ Antigen tests (rapid Strep kits) or
culture should be positive before
beginning antibiotic treatment.
Experts suggest confirming negative results
on antigen tests with culture. 5
Remember that most cases with clinical
signs of strep, like exudate and adenopathy, are viral.
allergic.
References
1. Schwartz B, Marcy SM, Phillips WR, Gerber MA, Dowell
SF, Pharyngitis-principles of judicious use of antimicrobial agents. Pediatrics 1998;101:171-174
2 . Tanz RR, Shulman ST. Diagnosis and treatment of group
A streptococcal pharyngitis. Semin Pediatr Infect Dis
1995;6:69-78.
3 . Poses RM, Cebul RD, Collins M, et al. The accuracy of
experienced physicians’ probability estimates for
patients with sore throat: implications for decision
making. JAMA 1985;254:925-29.
4 . Denson MR. Viral pharyngitis. Semin Pediatr Infect
Dis 1995;6:62-68.
5 . American Academy of Pediatrics. Group A streptococcal infections. In: Pickering LK, ed. 2000 Red Book:
Report of the Committee on infectious Diseases. 25th
ed. Elk Grove, IL: American Academy of Pediatrics;
2000:528.
6 . Middleton DB, D’ Amico FD, Merenstein JH. Standardized symptomatic treatment versus penicillin as
initial therapy for streptococcal pharyngitis. J
Pediatr 1988;113:1089-94.
7 . Shulman ST, Gerber MA, Tanz RR, Markowitz M.
Streptococcal pharyngitis: the case for penicillin
therapy. Pediatr Infect Dis J 1994;13:1-7.
CAREFUL ANTIBIOTIC USE
Cough illness in the well-appearing child: Antibiotics are
NOT the answer.
COUGH ILLNESS/BRONCHITIS1
Cough illness/bronchitis is
caused by viral pathogens.2
inflammation and sputum
are non-specific responses
imply a bacterial etiology.
principally
Airway
production
and do not
Authors of a meta-analysis of six
randomized trials (in adults) concluded
that antibiotics were ineffective in treating cough illness/bronchitis.3
Antibiotic treatment of upper respiratory
infections do not prevent bacterial complications such as pneumonia.4
■ When parents demand antibiotics...
Acknowledge the child’s symptoms and
discomfort.
Promote active management with
non-pharmacologic treatments.
Give realistic time course for resolution.
Share the CDC/AAP principles and pamphlets
with parents to help them understand when the
risks of antibiotic treatment outweigh the
benefits.
References
■ Do not use antibiotics for:
Cough <10-14 days in well-appearing child
without physical signs of pneumonia.
■ Consider antibiotics only for:
Suspected pneumonia, based on fever with focal
exam, infiltrate on chest x-ray, tachypnea, or
toxic appearance.
Prolonged cough (>10-14 days without
improvement) may suggest specific illnesses
(e.g. sinusitis) that warrant antibiotic
treatment. 5
Treatment with a macrolide (erythromycin)
may be warranted in the child older than 5
years when mycoplasma or pertussis is
suspected. 6
1.OBrien KL, Dowell SF, Schwartz B, Marcy SM,
Phillips WR, Gerber MA. Cough illness/bronchitisprinciples of judicious use of antimicrobial agents.
Pediatrics 1998;101:178-181.
2 .Chapman RS, Henderson FW, Clyde WA, Collier
AM, Denny FW. The epidemiology of tracheobronchitis in pediatric practice. Am J Epidemiol
1981;114:789-797.
3 .Orr PH, Scherer K, Macdonald A, Moffatt MEK.
Randomized placebo-controlled trials of antibiotics for
acute bronchitis: a critical review of the literature.
J Fam Pract 1993;36:507-512.
4 .Gadomski AM. Potential interventions for preventing pneumonia among young children: lack of effect
of antibiotic treatment for upper respiratory infections. Pediatr Infect Dis J 1993;12:115-120.
5.Wald E. Management of Sinusitis in infants and
Children. Pediatr Infect Dis J 1988;7:449-452.
6 .Denny FW, Clyde WA, Glezen WP. Mycoplasma
pneumoniae disease clinical spectrum, pathophysiology,
epidemiology and control. J Infect Dis 1971;123:74-92.
CAREFUL ANTIBIOTIC USE
When parents request antibiotics for rhinitis or the
“common cold”... Give them an explanation, not a prescription.
RHINITIS VERSUS SINUSITIS IN CHILDREN1
Remember:
Treating sinusitis:
Children have 2-9 viral respiratory illnesses
per year.2
In uncomplicated colds, cough and nasal
discharge may persist for 14 days or more –
long after other symptoms have resolved
Duration of symptoms in 139 rhinovirus colds
3
cough nasal discharge
fever myalgia sneezing sore throat
% of patients with symptom
% of patients with symptom
70%
60%
50%
40%
30%
20%
10%
0%
70%
60%
50%
40%
30%
20%
10%
0%
2 3 4 5 6 7 8 9 10 11 12 13 14
day of illness
■ Target likely organisms with
first-line drugs:
Amoxicillin, Amoxicillin/Clavulanate6
■ Use shortest effective course:
Should see improvement in 2-3 days. Continue
treatment for 7 days after symptoms improve
or resolve (usually a 10 - 14 day course).7
■ Consider imaging studies in
recurrent or unclear cases:
But remember that some sinus involvement is
frequent early in the course of uncomplicated
viral URI - so interpret studies with caution.
1 2 3 4 5 6 7 8 9 10 11 12 13 14
day of illness
Share the CDC/AAP principles and pamphlets
with parents to help them understand when
antibiotic treatment risks outweigh the
benefits.
■ rhinorrhea, fever, and cough are symptoms of
Controlled studies do not support antibiotic
treatment of mucopurulent rhinitis.4
Antibiotics do not effectively treat URI, or
prevent subsequent bacterial infections.5
Don’t overdiagnose sinusitis
Though most viral URIs involve the
paranasal sinuses, only a small minority are
complicated by bacterial sinusitis.
Avoid unneccesary treatment by using
strict criteria for diagnosis:5
Symptoms of rhinorrhea or persistent daytime cough lasting more than 10 - 14 days
without improvement.
or
Severe symptoms of acute sinus infection:
- fever (> 39 C) with purulent nasal dis
charge
- facial pain or tenderness
- periorbital swelling
viral URI
■ changes in mucous to yellow, thick, or green
are the natural course of viral URI, NOT an
indication for antibiotics.8
■ treating viral URI will not shorten the course of
illness or prevent bacterial infection.5
References
1. Rosenstein N, Phillips WR, Gerber MA, Marcy SM, Schwartz
B, Dowell SF. The common cold-principles of judicious use.
Pediatrics 1998;101:181-184.
2 . Monto AS, Ullman BM. Acute respiratory illness in an
American community. JAMA 1974;227:164-169.
3 . Gwaltney JM, Hendley JO, Simon G, Jordan WS. Rhinovirus infections in an industrial population. JAMA
1967;202:158-164.
4 . Todd JK, Todd N, Damato J, Todd WA. Bacteriology and
treatment of purulent nasopharyngitis: a double blind,
placebo-controlled evaluation. Pediatric Inf Dis J
1984;3:226-232.
5 . Gadomski AM. Potential interventions for preventing
pneumonia among young children: lack of effect of antibiotic
treatment for upper respiratory infections. Pediatric Infect
Dis J 1993;12:115-120.
6. Avorn J, Solomon D. Cultural and economic factors that
(mis)shape antibiotic use: the nonpharmacologic basis of
therapeutics. Ann of Intern Med 2000:133:128-135.
7 . O’Brien KL, Dowell SF, Schwartz B, et al. Acute sinusitis –
prin-ciples of judicious use of antimicrobial agents. Pediatrics 1998;101:174-177.
8 . Wald ER. Purulent nasal discharge. Pediatric Infect Dis J
1991;10:329-333.
CAREFUL ANTIBIOTIC USE
Stemming the tide of antibiotic resistance: Recommendations by CDC/AAP
to promote appropriate antibiotic use in children.1, 2
PEDIATRIC APPROPRIATE TREATMENT SUMMARY
DIAGNOSIS
Otitis Media
CDC/AAP Principles of Appropriate Use
1. Classify episodes of otitis media (OM) as acute otitis media (AOM) or otitis media with effusion (OME).
Only treat certain children with proven AOM.
2.
A certain diagnosis of AOM meets three criteria:
- History of acute onset of signs and symptoms
- Presence of middle ear effusion
- Signs or symptoms of middle-ear inflammation
Severe illness is moderate to severe otalgia or fever ≥ 39C.
Non-severe illness is mild otalgia and fever < 39C in the past 24 hours.
3.
Children with AOM who should be treated as follows:
Age
4.
Rhinitis and
Sinusitis
Pharyngitis
Cough Illness
and Bronchitis
Certain Diagnosis
Uncertain Diagnosis
< 6 mo
Antibacterial therapy
Antibacterial therapy
6 mo to 2 y
Antibacterial therapy
Antibacterial therapy if severe illness; observation option*
if nonsevere illness
>2y
Antibacterial therapy if severe illness; observation
option* if nonsevere illness
Observation option*
Don’t prescribe antibiotics for initial treatment of OME:
- Treatment may be indicated if bilateral effusions persist for 3 months or more.
* If decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children.
Rhinitis:
1. Antibiotics should not be given for viral rhinosinusitis.
2. Mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) frequently accompanies viral
rhinosinusitis. It is not an indication for antibiotic treatment unless it persists without improvement for more
than 10-14 days.
Sinusitis:
1. Diagnose as sinusitis only in the presence of:
- prolonged nonspecific upper respiratory signs and symptoms (e.g. rhinorrhea and cough without
improvement for > 10-14 days), or
- more severe upper respiratory tract signs and symptoms (e.g. fever >39C, facial swelling, facial pain).
2. Initial antibiotic treatment of acute sinusitis should be with the most narrow-spectrum agent which is active
against the likely pathogens.
1. Diagnose as group A streptococcal pharyngitis using a laboratory test in conjunction with clinical and
epidemiological findings.
2. Antibiotics should not be given to a child with pharyngitis in the absence of diagnosed group A streptococcal
infection.
3. A penicillin remains the drug of choice for treating group A streptococcal pharyngitis.
1. Cough illness/bronchitis in children rarely warrants antibiotic treatment.
2. Antibiotic treatment for prolonged cough (>10 days) may occasionally be warranted:
- Pertussis should be treated according to established recommendations.
- Mycoplasma pneumoniae infection may cause pneumonia and prolonged cough (usually in children > 5
years); a macrolide agent (or tetracycline in children ≥ 8 years) may be used for treatment.
- Children with underlying chronic pulmonary disease (not including asthma) may occasionally benefit
from antibiotic therapy for acute exacerbations.
When parents demand antibiotics…
†
†
Provide educational materials and share your treatment rules to explain when the risks of antibiotics outweigh the benefits.
Build cooperation and trust:
- Don’t dismiss the illness as “only a viral infection”
- Explicitly plan treatment of symptoms with parents
- Give parents a realistic time course for resolution
- Prescribe analgesics and decongestants, if appropriate
1. Dowell SF, Editor. Principals of judicious use of antimicrobial agents for children’s upper respiratory infections. Pediatrics. Vol 1. January 1998 Supplement.
2. American Academy of Pediatrics and American Academy of Family Physicians, Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004;113:1451-1.
CAREFUL ANTIBIOTIC USE
Make promoting appropriate antibiotic use part of your
routine clinical practice
PRACTICE TIPS
When parents ask for antibiotics to treat
viral infections:
Create an office environment to promote the reduction in antibiotic use.
■ Explain that unnecessary antibiotics
can be harmful.
■ Talk about antibiotic use at 4 and 12
month well child visits.
Tell parents that based on the latest evidence, unnecessary antibiotics CAN be
harmful, by promoting resistant organisms in
their child and the community.
■ Share the facts.
Explain that bacterial infections can be cured
by antibiotics, but viral infections never are.
Explain that treating viral infections with
antibiotics to prevent bacterial infections
does not work.
■ Build cooperation and trust.
Convey a sense of partnership and don’t
dismiss the illness as “only a viral infection”.
■ Encourage active management of
the illness.
Explicitly plan treatment of symptoms with
parents. Describe the expected normal time
course of the illness and tell
parents to come back if the
symptoms persist or worsen.
■ Be confident with the recommendation to use alternative treatments.
Prescribe analgesics and decongestants, if
appropriate.
Emphasize the importance of adequate
nutrition and hydration.
Consider providing “care packages” with nonantibiotic therapies.
The AAP Guidelines for Health Supervision III
(1997) now include counseling on antibiotic
use as an integral part of well-child care.
■ Start the educational process in the
waiting room.
Videotapes, posters, and other materials are
available.
(www.cdc.gov/ncidod/dbmd/antibioticresistance)
■ Involve office personnel in the
educational process.
Reenforcement of provider messages by office
staff can be a powerful adjunct to change
patient attitudes.
■ Use the CDC/AAP pamphlets
and principles to support your
treatment decisions.
Provide information to help parents understand when the risks of using antibiotics
outweigh the benefits.
A GUIDE FOR PARENTS QUESTIONS AND ANSWERS
Runny Nose (with green or yellow mucus)
Y
our child has a runny nose. This is a
normal part of what happens during the
common cold and as it gets better. Here are
some facts about colds and runny noses.
What causes a runny nose during
a cold?
When germs that cause colds first infect the nose
and sinuses, the nose makes clear mucus. This
helps wash the germs from the nose and sinuses.
After two or three days, the body’s immune cells
fight back, changing the mucus to a white or
yellow color. As the bacteria that live in the nose
grow back, they may also be found in the mucus,
which changes the mucus to a greenish color.
This is normal and does not mean your child
needs an antibiotic.
Are antibiotics ever needed for a
runny nose?
Antibiotics are needed only if your healthcare
provider tells you that your child has sinusitis.
Your child’s healthcare provider may prescribe
other medicine or give you tips to help with a
cold’s other symptoms like fever and cough, but
antibiotics are not needed to treat the runny
nose.
Why not try antibiotics now?
What should I do?
• T
he best treatment is to wait and watch your
child. Runny nose, cough, and symptoms
like fever, headache, and muscle aches may be
bothersome, but antibiotics will not make
them go away any faster.
• S ome people find that using a cool mist
vaporizer or saltwater nose drops makes their
child feel better.
Taking antibiotics when they are not needed can
be harmful. Each time people take antibiotics,
they are more likely to carry resistant germs in
their noses and throats. These resistant germs
cannot be killed by common antibiotics. Your
child may need more costly antibiotics,
antibiotics given by a needle, or may even need
to be in the hospital to get antibiotics. Since a
runny nose almost always gets better on its own,
it is better to wait and take antibiotics only when
they are needed.
1-800-CDC-INFO
www.cdc.gov/getsmart
GUÍA PARA PADRES PREGUNTAS Y RESPUESTAS
Goteo nasal (con mucosidad verde o amarilla)
u hijo tiene un goteo nasal. Esto es normal durante
el resfriado común y cuando comienza a curarse.
A continuación se presentan algunos datos sobre
los resfriados y el goteo nasal.
S
¿Qué causa el goteo nasal durante
un resfriado?
Cuando los gérmenes que provocan el resfriado
infectan primero la nariz y los senos nasales, la nariz
produce una mucosidad transparente. Esto ayuda a
limpiar la nariz y los senos nasales de gérmenes.
Después de dos o tres días, las células inmunológicas
del cuerpo se defienden y el color de la mucosidad
se vuelve blanco o amarillo. A medida que las bacterias
que viven en la nariz vuelven a proliferar, también
se encuentran en la mucosidad y esto varía su color
a un tono verdoso. Esto es normal y no significa
que su hijo necesite antibióticos.
¿Es posible que se necesiten antibióticos
para tratar el goteo nasal?
Los antibióticos se necesitan solamente si su médico
dice que su hijo tiene sinusitis. El médico de su hijo
puede recetar otros medicamentos o aconsejarle acerca
de cómo tratar los demás síntomas del resfriado como
la fiebre y la tos, pero no se necesitan antibióticos para
tratar el goteo nasal.
¿Por qué no probamos con los
antibióticos ahora?
¿Qué debo hacer?
• El mejor tratamiento es esperar y observar a su hijo.
El goteo nasal, la tos y los síntomas como fiebre,
dolor de cabeza y dolor muscular pueden ser
molestos, pero los antibióticos no los harán
desaparecer más rápido.
• Algunas personas creen que utilizar un vaporizador
de vapor frío o gotas de agua salada para la nariz
hace que sus niños se sientan mejor.
Tomar antibióticos cuando no es necesario puede
resultar perjudicial. Cada vez que una persona toma
antibióticos, los gérmenes dentro de la nariz y de la
garganta tienen mayor probabilidad de volverse
resistentes. Estos gérmenes resistentes no se pueden
eliminar con antibióticos comunes. Su hijo podría
necesitar antibióticos más costosos, antibióticos
inyectables o incluso ser hospitalizado para obtener
los antibióticos. Dado que el goteo nasal casi siempre
se resuelve solo, es mejor esperar y tomar antibióticos
solamente cuando se necesitan.
www.cdc.gov/antibioticos